Citizens Medical Center Ltcu

In the surveyor’s words

From the most serious findings on record at Citizens Medical Center Ltcu, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Jun 5, 2024

  The facility identified a census of 44 residents with three residents reviewed for neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 who had a history of respiratory failure and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) received the required respiratory services. On 05/21/24 at 09:58 AM Certified Nurse Aide (CNA) M failed to provide R1's continuous oxygen at 4 Liters (L) per minute for forty-five minutes, while staff provided R1 a bath. At 10:45 AM CNA M assisted R1 back to his wheelchair after bathing and dressing him; when R1 sat down he became unresponsive. […]

• Actual harm, isolatedF692Oct 13, 2022

  The facility had a census of 48 residents. The sample included 13 residents, with three reviewed for nutrition. Based on observation, record review, and interview, the facility failed to identify weight loss and involve the Registered Dietician (RD) for weight loss interventions to address the significant unplanned weight loss for one sampled resident, Residents (R) 20. The facility further failed to monitor nutritional supplement intake for R20 after the significant loss to evaluate the effectiveness of the intervention. […]

• Actual harm, isolatedF689Mar 22, 2022

  The facility documented a census of 48 residents. The sample included three residents with three reviewed for falls. Based on observation, record review, and interview, the facility failed to implement safety protocols while using a whirlpool lift chair to prevent falls. As a result of this deficient practice, Resident (R) 1 fell out of the whirlpool lift chair and sustained a right [CONDITION(S)]. Findings included: - R1's Electronic Medical Record (EMR) documented R1 admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), repeated falls, and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF730Jul 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure the required annual performance reviews were completed for four randomly selected nurse aides reviewed. Findings included:- A review of the facility nurse aide performance evaluations revealed that Certified Nurse Aide (CNA) O, with an employment date of 10/23/24, CNA P, with an employment date of 03/12/24, CNA Q, with an employment date of 10/05/10, and CNA R with an employment date of 12/06/23, randomly selected employees who had been employed for over a year, lacked an annual performance review. On 07/07/2026 at 02:30 PM, Administrative Staff A reported that the CNAs lacked annual performance reviews. […]

• No harm, potential for more than minimal, patternF607Jul 8, 2026

  Based on record review and interview, the facility failed to implement a policy to screen potential employees for a history of abuse, neglect, exploitation, or misappropriation when the facility failed to obtain a criminal background check and license verification upon hire of a Licensed Nurse (LN) I. Findings included:- Upon request, a randomly selected LN I, who had an employee start date of 02/14/2022, the facility was unable to provide documentation of criminal background and nurse registry check. On 07/07/2026 at 02:30 PM, Administrative Staff A reported a change in the system which had the verification of criminal background check and licensing verification documentation. […]